Privacy complaint - Internal review application form
Download the PDF version of this form here Privacy Complaint: Internal Review Application Form, updated September 2019
This is an application for review of conduct under: (please select one)
- section 53 of the Privacy and Personal Information Protection Act 1998 (PPIP Act)
- section 21 of the Health Records and Information Privacy Act 2002 (HRIP Act)
Your completed form must be sent to the Agency listed in Question 1 below.
1. Name and address of the agency you are complaining about:
__________________________________________________
2. Your full name
__________________________________________________
3. Your contact details
Postal address
__________________________________________________
Telephone number
__________________________________________________
Email address
__________________________________________________
4. If the complaint is on behalf of someone else, please provide their details:
__________________________________________________
What is your relationship to this person (e.g. parent)?
__________________________________________________
Please include details of your authority to act or make the complaint on behalf of the person you have named above.
__________________________________________________
Is the person capable of making the complaint by himself or herself?
Yes
No
Unsure
5. What is the specific conduct you are complaining about? Describe what you believe the Agency did. (see footnote for explanation of "conduct")
__________________________________________________
__________________________________________________
6. Please tick which of the following describes your complaint: (you may tick more than one option)
- collection of my personal or health information
- security or storage of my personal or health information
- refusal to let me access or find out about my own personal or health information
- accuracy of my personal or health information
- use of my personal or health information
- disclosure of my personal or health information
- other
- unsure
7. When did the conduct occur (date)? (please be as specific as you can)
__________________________________________________
8. When did you first become aware of the conduct (date)? (please be as specific as you can about how
and when you first became aware of the conduct. Please include any action that you took at the time)
__________________________________________________
9. You need to lodge this application within six months of the date at question 8.
If more than six months has passed, you will need to ask the agency for special permission to lodge a late application. Please explain why you have taken more than 6 months to make your complaint (for example: I had other urgent priorities - list them, or while the conduct occurred more than 6 months ago, I only recently became aware of my privacy rights, etc.):
__________________________________________________
__________________________________________________
10. What effect did the conduct have on you?
__________________________________________________
__________________________________________________
11. What effect might the conduct have on you in the future?
__________________________________________________
12. What would you like to see the agency do about the conduct? (For example: an apology, a change in policies or practices, your expenses paid, damages paid to you, training for staff, etc)
__________________________________________________
I understand this form will be used by the agency to process my request for an internal review. I understand that details of my application will be referred to the Privacy Commissioner in accordance with: section 54(1) of the Privacy and Personal Information Protection Act; or section 21 of the Health Records and Information Privacy Act; and that the Privacy Commissioner will be kept advised of the progress of the internal review.
Your signature:
__________________________________________________
Date:
__________________________________________________
SEND THIS FORM TO THE AGENCY YOU HAVE NAMED AT Q.1
Keep a copy for your records.
For more information on the PPIP Act or the HRIP Act, visit our website: www.ipc.nsw.gov.au.
